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t1 <br /> fm% tIFS <br /> 11'�1 (�AQ U N Environme to t o cert <br /> U '`I <br /> 0D INTY.... <br /> DECD 12017 <br /> UST SYSTEM RETROFIT OR REPAIR Ni/%NMF.NTAL HEALTH <br /> (Submit minimum of 3 sets of plans&applications as originals will be retai ed by �, WP +RTMENT <br /> 1. Site map enclosed? YES [] VO* ] <br /> 2. Submit copies of ICC Service Technician and/or Installer's certificate and all manufacturer training <br /> certificates for each person installing or testing any component that is repaired or replaced. Ensure a copy of <br /> the"Site Health and Safety Plan" is available on the jobsite as required by Title 8. <br /> 3. Detailed description of work to be completed. List components to be repaired or replaced and attach a <br /> diagram drawn to scale showing location of repairs and/or replacements. If repairing a component, describe <br /> how this will be done. (If adding piping, UDC's, or other UST equipment, or performing tank top upgrade, <br /> use the UST InstallationliFation iIages 4-8 as necessary for a timely plan review): <br /> �IL GSLc .xy <br /> z�rc SFtint+� •rie_ ' ��� �t <br /> w f�i�r/� e,�or U n��. c�,Q,Q u�:x C�4 j�� U D c _,. <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> ��PJO VZ'r- -dz A r gLf 795o <br /> 5. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES[] NO [e <br /> b. Identify contractor performing decontamination: <br /> Name eLvm it✓ 9S 5 Ill Phone (2.07) 461 b.1 <br /> Address CA City SP416-:�-4A Zip 7 <br /> 30?6 <br />